UNDERSTANDING THE APPEALS PROCESS

What is an appeal?

An appeal is a request to your insurance company for review of a denied claim or service.

A denial by your insurance company indicates that they have decided not to pay for the claim or service recommended by your physician. Even if you follow prior authorization and claims submission processes accurately, your insurance company may still deny your request for coverage.

How do I know if my claim has been denied?

If you have received services and the claim is denied, you and/or your medical provider should receive an Explanation of Benefits (EOB). If a portion of the claim was denied, there will be an explanation detailing the reason for the denial.

If a prior authorization is denied, you and/or your medical provider should receive a letter stating the reason for denial.

Carefully review these statements and use them to assist with submission of an appeal.

Did you know…

Oftentimes, a claim denial can be attributed to errors or incomplete information.

In
these cases, you or your doctor can simply make the necessary
corrections and resubmit the claim or request.

Why would my insurance company not cover my treatment?

There are numerous reasons that insurance companies may deny services or claims. It is important to review the reason your claim is denied as it helps you determine your next steps.Learn more

How do I make an appeal?

The process for appealing a denial will vary among health plans. When calling your insurance company regarding the denial, the first step should be to request a copy of the denial if you do not already have one. You should also inform your insurance company that you wish to appeal their denial and ask about the appeal process. Learn more

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The information provided on the PHA website is provided for general information only. It is not intended as legal, medical or other professional advice, and should not be relied upon as a substitute for consultations with qualified professionals who are familiar with your individual needs. PHA does not endorse or recommend any commercial products or services.